Life on Abram Lake
Life as a rural physician Mama in the backwoods of Northwestern Ontario
The Medicine
Writer’s note: the patients in this piece are composites of multiple patient encounters to preserve patient confidentiality.
CTAS 3. Suicidal ideation, possible toxic Advil ingestion. Hallway chairs.
The metal clipboard clatters onto the desk as I flop into the worn chair in the doctor’s ER charting room. It pitches me forward at an awkward angle as I hammer my password for the millionth time that shift into the desktop login screen. Workplace ergonomics clearly hasn’t been a priority for the many weary bums who have briefly rested here before me. Little red ambulance icons fill the screen as I load the patient’s electronic chart revealing previous ER visits for similar presentations.
Through the glass, I glance at the nurses’ station where a comically small black bin provides a landing place for ER charts of patients waiting to be seen by me, the solo MD in our busy department at the Sioux Lookout Meno Ya Win Health Centre. It’s an impossible dance, trying to keep pace with the growing pile. Ambulances pulling into the bay unloading medivacs from the North – patients already triaged to be the sickest of the sick, paramedics wheeling in gurneys of people picked up within town limits and of course, the seemingly neverending stream of walk-in patients presenting to triage.
Today is a shit day.
It’s a shit day because it is only an hour into my shift and already that ridiculous little bin has been shifted perpendicular to its usual position to make room for the endless stream of new ER registrants’ charts. Shortness of breath, weakness, abdominal pain, alcohol intoxication, back pain, ‘weak and dizzy’ – an endless barrage of chief complaints. Charts on top of charts, piling up, flowing from the confines of the inbox, snaking across the filing cabinet and now haphazardly falling to the floor.
A sideways chart day is never a good day.
Sighing, I make my way to the chair in the hallway that seats my next patient. Mental health assessments are never quick and I settle in beside her pulling my favourite pen from its usual spot lodged into the base of my ponytail. I long for a quick UTI, a prescription refill or a rash, something to help me catch up, but alas, this is not the case.
Lab techs whiz by us, coaxing white carts with clattering phlebotomy supplies through the maze of patients and IV poles clogging the hallway. Someone pounds insistently from the waiting room on the locked ER doors. The phone rings desperately as the clerk speaks rapidly on the other line. It’s not even close to an ideal place to inquire about one’s ugliest truths, but it’s all I’ve got. At least I’ve found two chairs.
My patient’s heavily-pierced face folds into a bright smile as I sit, her thickly-lined eyes disappearing into her grin. Her bright, outlandish outfit contrasts the bland grey and white hues of the department. We know each other well. A ‘friendly face’, as we call patients who come through our ER more regularly than some of our staff.
Today, she’s not interested in chatting. She grabs my hand and immediately pulls me into a hug.
Now, if you are in medicine, the thought of sitting in the ER hallway, letting a potentially unstable mental health patient hug you may be beyond unimaginable. I hear you. But as I sit there in her embrace, the comings and goings of the noisy ER flowing around us, more charts most definitely piling higher in that damn little box, I think of how little my medical ‘practice’ has to do with the actual practice of Western medicine. I relax my body and wait.
Minutes later she lets go, smiling her crinkly smile. We chitchat about her day and she tells me about her latest happenings since we last saw each other. I share an earbud and listen to the loop of her new favourite Top 40 hit as Justin Beiber struts across the screen of her beat-up iPhone. As I scrounge around the ER for a juice box and sandwich and in exchange, she agrees to my request for bloodwork and cardiac monitoring. Later, after Poison Control has been contacted and she’s medically cleared, she hands me a drawing she’s completed: a thank you note, brandishing a multitude of bright red hearts coloured in scented markers.
I step gingerly past the pile of ER charts still waiting for my attention and tape her drawing squarely onto the glass separating the doctors’ room and the chaotic nurses’ desk. Toxicology and acid-base physiology be damned, this is the medicine that matters. This is the medicine that fuels me. This is the medicine that I know I’ll die practicing.
After a year away from the Sioux Lookout Meno Ya Win Health Centre, nothing has changed, yet everything has changed. Post-COVID, human resource shortages are crippling across sectors without reservation, but health care has taken a weighty hit. At baseline, recruitment and retention of healthcare providers in our remote region have always been challenging. Complex patients, a high rurality index, virtually zero affordable housing and an exorbitant cost of living have always been colossal barriers. With a national nursing crisis, the situation in our little community has recently become dire.
Our small hospital, once staffed by local nurses who had spent their careers taking care of our patients has now been filled with nearly all agency nurses – temporary staff providing a warm body, filling an empty line in the schedule for a few quick months. Turnover is high, with nurses coming and going, mostly dropping in from the GTA to make a large amount of cash in a short period of time. Doctors being flown in from Toronto or other urban centres to cover a single ER shift all in an effort to keep the hospital doors open. Our Maternity nurses, once an integral part of our tight-knit program, colleagues on whom you relied on through tough cases are essentially all but gone, again replaced by temporary, agency nurses.
To these adventurous agency nurses, I am incredibly grateful. Most have proven to be fantastic – quick to learn, bringing knowledge and expertise from larger centres. Yet, without prior knowledge or understanding of our Region, the historical perspective of Indigenous peoples in this country, and knowledge of the intergenerational trauma and socioeconomic factors that continue to play a significant role in one’s ability to be well, it is difficult to truly provide medical care. Yes, of course, IVs continue to be started, medications administered, vitals taken, and physician orders executed, but in a sense, without trauma-informed, culturally-safe care, it all just seems so meaningless.
As threats of ER closures continue and human resource staffing plummets to an all-time low, not a day goes by where I don’t witness further erosion of empathy and care in the bare-bones operation of healthcare in our current political and economic climate. Nurses, doctors, clerks, housekeeping staff, lab techs – all of the folks that keep the cog turning are scraping from the bottom of the barrel to remain afloat and I’m terrified to see what will come next.
In our ER, I love being the 2-10pm guy. It’s the busiest shift by far but it allows me to see the kids in the morning and still sleep in my own bed at night. Today, as I lock my bike outside the ER entrance, saying farewell to the bright, sunny cloudless summer day, I already know it’s going to be a crazy shift. Two cop cars are parked out front, the ambulance bay is full and a flight from one of the larger communities must have just landed as all at once, at least ten patients are waiting to be triaged. Luggage bags and Tim Hortons take-out trays litter the floor of the waiting room. Balancing my coffee mug, I swipe myself into the ER, stepping carefully over a patient snoozing on the floor, sunglasses covering his eyes, his back slumped against the wall.
The trickiest part of the 2-10pm shift is dealing with the higher volumes of patients without any physical rooms to see people in. With no available beds on the inpatient wards, the steady influx of newly admitted patients clog up the ER all the while patients just keep on coming. Because of this, one of the first things I do at every shift is to take stock of where patients are, which patients could possibly be moved and where I could possibly squeeze someone new in.
Today, as I run through the ER whiteboard with my morning MD colleague, we realize that there is a patient who had been handed over from the overnight physician and had yet to be reassessed. Unfortunately, this happens all too often. Errors in care occur most commonly for patients who change hands from physician to physician during their stay in the ER department. People simply get lost in the shuffle.
Anxious to potentially free up this patient’s bed, I grab his chart and make my way down the hall and into a windowless room around the corner, away from the hustle and bustle of the nursing desk. A middle-aged man rests quietly on the gurney – no iPhone, no TV, no magazine or book to provide a mental escape from the incessant waiting. A quick glance around reveals no family member or friend accompanying him. The ER chart indicates he is from Poplar Hill, a fly-in Anishinaabe community of 500 people, some 300 kilometres north of Sioux Lookout. Sent to the ER by the community physician for an abdominal ultrasound, he had been triaged the evening prior, assessed by the overnight physician then held in the department for a morning ultrasound. Often patients are asked not to eat or drink prior to this type of investigation to allow for optimal views but in the morning change of guard, his ultrasound hadn’t been ordered, his chart was missed and thus he had been waiting patiently without anything to eat or drink for now over 14 hours.
“But his legs aren’t broken,” responds the nurse when I ask how this gentleman had been so grossly overlooked. “He could have come up to the desk and asked for food!” she says matter-of-factly. I know she’s not being unkind. From a large hospital in Southern Ontario, she’s at the end of her career and she’s truly seen it all. Efficient and with a no-nonsense attitude, she runs our department with a decisive air.
In this moment, I am not sure if I should rage or cry. I know I need to keep hustling, but instead, I spend the next five minutes ranting about the multitude of reasons why our shared patient will never march up to the nursing desk and demand food. I rattle on about the long history of racism and mistrust between our communities and government institutions such as our hospital, the power imbalance between patient and provider, often enhanced greatly by limited health literacy, language barriers and cultural differences. I notice her face shifting, softening. I carry on. We talk about poverty, trauma, residential schools and how this plays into every encounter, every single day in our hospital. I paint a picture of how a patient moves through the system from the first presentation to the nursing station, onto a plane with little prior notice, before ending up in our department many, many hours later, usually hungry, alone, exhausted and often without any belongings.
“I didn’t know,” she admitted. I laugh, ‘That’s why you think I’m always crazy running around the hospital at all hours scrounging up iPhone chargers, warm blankets, sandwiches and shoes!’ She smiles back, and for a moment, there is a collective remembering of why we chose our professions – why we still keep showing up. Despite the sinking ship and the chaos that surrounds us, together I know that we both can still hear the orchestra playing.
In medical school, I sat through countless lectures on medical professionalism, health advocacy, ethics and boundaries. In usual form, tidy notes were taken, passages memorized and exams passed. When I arrived in Sioux Lookout as a naive, bright-eyed third-year medical student, I felt confident in my knowledge, full of excitement and wonder about this new adventure in medicine. I was brimming with textbook wisdom of how things ought to be.
On the ground, the tidy boxes of colour-coded notes floating in my brain were soon in disarray – my patients and colleagues as my new teachers, rapidly dismantling my learned ideologies. My passion for medicine had always been grounded in the humanity of it all and I immediately delighted in watching my newfound mentors demonstrate what health advocacy truly looked like. Theoretical, academic treaties suddenly felt useless in the face of what our patients were encountering on a day-to-day basis. Of course, boundaries in medicine are vital to ensure patients and providers are safe, but what I witnessed daily in the provision of medical care in those early years in Sioux Lookout was so much more than order sets and antibiograms.
Practicing medicine meant noticing that it was a patient’s birthday on her post-partum visit with a medically complicated newborn in tow and hastily passing around a birthday card to be presented with the patient’s favourite drink from the cafeteria. It meant bringing a treasured Tim Horton’s double-double to a hospitalized Elder without family nearby. It meant giving rides and gathering newborn items for a struggling family. It meant pulling out your VISA after hours to pay for flights in order to reunite family members after an unexpected tertiary care centre transfer and birth, long after administrators and management had gone home. It meant spending extra time on the phone with the funeral home and lab to ensure the fetal remains of a woman’s miscarriage were safely brought home to her community for ceremony. It meant looking beyond the diagnosis and truly hearing the patient’s story, taking the time to ask ‘what has happened to this person in their life to have brought them to this place of struggle’. It meant partnering with communities to relentlessly fight for medical equipment, mental health services and basic needs like housing, clean water and access to education.
While in medical school I was taught to maintain professional distance, uphold patient-physician boundaries, never get too attached, limit my emotional expenditure and dissociate to provide optimal care. Yet, what I saw every single day in practice in Sioux Lookout did not match what I had learnt in my lecture hall. My colleagues unabashedly pushed through the confines of those tidy boxes without a backwards glance. Unapologetically, tirelessly and relentlessly advocating for their patient’s needs – both big and small.
As a green medical student, I was shocked at their audacity to challenge what I had been traditionally taught about boundaries, and professionalism in medicine. It was profoundly formative as patients and colleagues revealed to me how intimately intertwined medicine and advocacy were. All the antibiotics in the world would not do a damned thing in treating a patient’s post-op wound infection if there wasn’t also stable housing, as well as addictions and mental health services that were equally prioritized.
Last winter, I took my first sustained break from medical practice in Sioux Lookout since the beginning of my career as a newly minted MD, straight out of residency eight years prior. Despite locuming in a new community with perfectly lovely patients and colleagues, I struggled with nightly feelings of emptiness at the end of my clinic days. Something just didn’t feel right. My grief and longing for my colleagues and work in Sioux Lookout forced me to peer deeply inwards and question what was it about my medical practice that I missed so profoundly. Could it be that despite the chaos, through the most challenging patient encounters, these acts of empathy and advocacy, both big and small bonded us, both patients and physicians together, building resilience and connection? Could it be that in making an effort to truly see our patients, we were perhaps not the only healers? Could it be that through these acts, conceivably, our patients were, in fact, the ones healing us in return?
These days, headlines trumpet our crumbling healthcare system and not a shift passes in my clinical work that I don’t see its effects on patients and families. Now back in British Columbia working at the local urgent care centre, virtually every patient encounter begins with the same troubling statement: ‘I don’t have a family doctor anymore…’ Patients struggling with complex medical and social concerns, attempting to navigate and understaffed, underfunded medical system with no one in their corner. Family physicians, the quarterbacks of the medical ‘home’, have been chronically underpaid and grossly overworked for decades. Understandably, post-COVID, burnt out, they are now quitting in droves and very few brave souls are entering this line of work after medical school to take their places.
To put it simply, it’s a mess and I am worried.
Worried, of course by the obvious medical consequences – delayed cancer diagnoses, rising mental health crises and drug overdoses, surging cardiac and cerebrovascular events while preventative health disintegrates, but even more desperate, as staffing shortages climb and our human resources continue to drain, lack of empathy and compassion fatigue prevail. Humanity is the first to go at the bedside and this is what I’m most fearful of. Of course, the cog will continue to turn, thrombolytics will be administered, and scalpels will excise cancers but If we cannot continue to connect with each other and to our patients through empathy and story, the relationship of bidirectional healing and reciprocity will wither and I, for one, know I will not be sustained in this profession as a result.
In the delivery room, the newborn wails, calling out its first few breaths against his mother’s chest. She smiles quietly, holding his slippery body tightly. The nurse administers medication to prevent bleeding, records vitals and swiftly tidies the evidence of the birth as I examine the baby, a pink neonatal stethoscope against the tiny chest, smiling at the woman as I listen to the usual thrum of the babe’s heart. We had met many times prior to her delivery – her sixth little one arriving on the heels of her two-year-old’s birthday back home. She was here alone, her partner providing care for their family with no one else reliable to either come to Sioux Lookout or provide childcare back home, hundreds of kilometres away. Reaching for her iPhone at the bedside, I ask if she’d like me to take some photos to send home. ‘The camera is broken,’ she responds matter-of-factly not breaking her gaze at her new babe’s howling face. No photos, no FaceTime, no bridge to share this momentous occasion with those whom she loved. My heart squeezes tightly at the loss. Within minutes, my patient becomes my newest Facebook friend and with permission, intimate photos of those first precious moments move across the ether from my phone to hers, a boundary-crossing that surely would not have been condoned by my medical school professors. But there it is. A connection, for a moment, not between doctor and patient, but between mothers, between humans. A gift to both of us.
This is the medicine that will sustain us and I am certain, this is the medicine that will continue to heal.
Life on Abram Lake 